Coronary Revascularization in Patients with CKD Stage 5D: Pragmatic Considerations

Abstract

Coronary revascularization decisions for patients with CKD stage 5D present a dilemma for clinicians because of high baseline risks of mortality and future cardiovascular events. This population differs from the general population regarding characteristics of coronary plaque composition and behavior, accuracy of noninvasive testing, and response to surgical and percutaneous revascularization, such that findings from the general population cannot be automatically extrapolated. However, this high-risk population has been excluded from all randomized trials evaluating outcomes of revascularization. Observational studies have attempted to address long-term outcomes after surgical versus percutaneous revascularization strategies, but inherent selection bias may limit accuracy. Compared with percutaneous strategies, surgical revascularization seems to have long-term survival benefit on the basis of observational data but associates with substantially higher short-term mortality rates. Percutaneous revascularization with drug-eluting and bare metal stents associates with a high risk of in-stent restenosis and need for future revascularization, perhaps contributing to the higher long-term mortality hazard. Off-pump coronary bypass surgery and the newest generation of drugeluting stent platforms offer no definitive benefits. In this review, we address the nuances, complexities, and tradeoffs that clinicians face in determining the optimal method of coronary revascularization for this high-risk population.

One-year clinical outcomes in patients with renal insufficiency after contemporary PCI: data from a multicenter registry

“…While CABG was shown to be superior to PCI in patients with multivessel CAD and endstage renal disease regarding long-term survival, PCI was superior to CABG in short-term survival, stroke, and repeat revascularization [11]. However, data on the long-term performance of new-generation DES indicate no significant difference between PCI and CABG in patients with CKD [11][12][13][22][23][24]. Previous studies on revascularization have shown that patients with CKD after PCI and CABG are at increased risk of death and adverse events, correlating with the severity of renal insufficiency [23][24][25].…”

“…Severe and diffuse CAD is prevalent in patients with CKD [5][6][7][8][9][10]. In those patients, revascularization options include coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) [11][12][13]. Adverse event rates following PCI and CABG were significantly higher in CKD patients when compared to patients with normal renal function [5][6][7][8][14][15][16].…”

“…Adverse event rates following PCI and CABG were significantly higher in CKD patients when compared to patients with normal renal function [5][6][7][8][14][15][16]. Moreover, these patients differ from the general population concerning symptoms of acute cardiac events, poor access sites, complex vascular lesions, and a higher rate of complications [8,[13][14][15][16][17][18]. However, patients with CKD are under-represented in clinical studies on revascularization, and, thus, knowledge on performance of PCI using newest-generation drug-eluting stents (DES) is limited [9,13].…”

“…Moreover, these patients differ from the general population concerning symptoms of acute cardiac events, poor access sites, complex vascular lesions, and a higher rate of complications [8,[13][14][15][16][17][18]. However, patients with CKD are under-represented in clinical studies on revascularization, and, thus, knowledge on performance of PCI using newest-generation drug-eluting stents (DES) is limited [9,13]. We aimed at evaluating the outcomes following revascularization using contemporary technologies (abluminal sirolimus-eluting stents with thin struts) in patients with CKD (defined as an estimated glomerular filtration rate of < 60 mL/min/1.73m 2 ) including a subgroup of patients undergoing hemodialysis (HD) in the prospective, singlearm, multi-center, international e-Ultimaster registry.…”

Screening Transplant Waitlist Candidates for Coronary Artery Disease

“…The patient did not have occlusive disease (i.e., stenosis $70%) that would normally warrant revascularization (6). The relevant considerations regarding revascularization include the fact that the degree of coronary stenosis does not predict future plaque rupture and that 30% of perioperative myocardial infarctions occur in areas supplied by arteries with nonocclusive plaque (7,8). In this patient, a large territory of myocardium would be at risk in the event of a myocardial infarction.…”